Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. General Survey, Measurement, Vital Signs Health Assessment Across the Lifespan NRS 102
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-2 General Survey Physical appearance Age Sex Level of consciousness Skin color Facial features Body structure Stature Nutrition Symmetry Posture Position Body build, contour
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-3 General Survey (cont.) Mobility Gait Range of motion Behavior Facial expression Mood and affect Speech Dress Personal hygiene
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-4 Measurement Weight Balance scale Recommended range for height Height
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-5 Vital Signs Temperature Hypothalamus as thermostat mechanism Influences on temperature Diurnal cycle Diurnal cycle Menstrual cycle Menstrual cycle Exercise Exercise Age Age Routes of temperature measurement Oral Oral Electronic thermometer Electronic thermometer Axillary Axillary Rectal Rectal Tympanic membrane thermometer Tympanic membrane thermometer
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Abnormal Body Temp Hypothermia Heat loss during prolonged exposure to cold Classified by core temp (mild-severe) May be intentional (surgery) Early signs- uncontrolled shivering, loss of memory, poor judgment Later signs- Cyanosis, decreased VS, cardiac dysrhythmias, loss of consciousness Frostbite- body exposure to subnormal temps
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Abnormal Body Temp Hyperthermia Elevated body temp related to body’s inability to promote heat loss or reduce heat production Heatstroke- prolonged exposure to sun or high environmental temp. Heat depresses hypothalamus function Heat Exhaustion- profuse diaphoresis result in fluid & electrolyte loss
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-10 Pulse Stroke volume Technique of measurement Rate Normal rate for age group Normal rate for age group Bradycardia Bradycardia Tachycardia Tachycardia Rhythm Sinus arrhythmia Sinus arrhythmia Force Elasticity Vital Signs
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-13 Respirations Technique of measurement Normal rate for age group Ratio of pulse rate to respiratory rate should be approximately 4:1 Vital Signs
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Assessing Respirations Assessing rate- observe full inspiration & expiration Assess for full minute Normal adult 12 –20 breaths/minute Varies with age, rate declines throughout life Apnea Monitor
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Normal & Abnormal Respirations Eupnea- normal respirations Bradypnea- abnormally slow < 12 Tachypnea- abnormally fast >20 Hyperpnea- labored, after exercise Hyperventilation/Hypoventilation Cheyne-Stokes Kussmauls Biot’s
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-16 Blood pressure Systolic pressure Diastolic pressure Pulse pressure Mean arterial pressure Vital Signs
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-17 Blood Pressure
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-18 Influences on blood pressure Age Age Race Race Weight Weight Emotions Emotions Sex Sex Diurnal rhythm Diurnal rhythm Exercise Exercise Stress Stress Vital Signs
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-19 Physiologic factors controlling blood pressure Cardiac output Cardiac output Peripheral vascular resistance Peripheral vascular resistance Volume of circulating blood Volume of circulating blood Viscosity Viscosity Elasticity of vessel walls Elasticity of vessel walls Vital Signs (cont.)
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-20 Factors Controlling Blood Pressure Illustration Pat Thomas, © 2006
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-21 Vital Signs Blood pressure measurement Sphygmomanometer Cuff width and size Blood pressure measurement in the arm Position of person Position of person Palpate brachial artery Palpate brachial artery Proper inflation and deflation technique Proper inflation and deflation technique Korotkoff’s sounds Korotkoff’s sounds I, systolic pressure IV, muffling of sounds V, diastolic pressure
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-22 Measuring Blood Pressure
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-23 Vital Signs Common errors in blood pressure measurement Orthostatic (or postural) hypotension Blood pressure measurement in the thigh Thigh pressure higher than in the arm Thigh pressure higher than in the arm Screen for coarctation of aorta Screen for coarctation of aorta
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Assessment of Diffusion & Perfusion Assessed by oxygen saturation of blood Oxygen attaches to hemoglobin molecule in RBC % of hemoglobin that is bound with oxygen in the arteries is the % of saturation of hemoglobin (SaO2) Usually % Affected by factors that interfere with ventilation, diffusion, & perfusion
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Measurement of Arterial Oxygen Saturation Pulse oximeter Allows indirect measurement of oxygen saturation SpO2 is a reliable estimate of SaO2 Measurement is affected if extremity is cold, edematous or if nail polish is present (interference with light transmission)
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-27
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-28 Sample Charting
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-29 Significant elevation in blood pressure measurements from one day to the next could be attributed to A.A decrease in cuff size B.An increase in cuff size C.New onset of pain or anxiety D.A and C
Elsevier items and derived items © 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Chapter 9: General Survey, Measurement, Vital Signs Slide 9-30 Which patient would be most likely to present with a pulse rate that is lower than normal? A.A 70-year-old telephone salesman presenting with dehydration. B.A 20-year-old runner who had surgery 4 days ago for a fractured leg. C.A 67-year-old who presented with an exacerbation of his COPD